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Medicare Part D Benefit:
A Primer
Missy Jenkins
Vice President, Federal Affairs
October 31, 2005
Medicare Part D
 PBM participation in Part D is robust.
 PCMA members are 5 of the 10 national PDPs, and one regional PDP.
– Premiums and formulary coverage offered are competitive with other plans.
 PBMs will be contracting and supporting MA-PDPs to provide the drug
benefit.
 Assisting employer clients determine the right way to participate
(subsidy, wrap around, direct sponsor).
– Most employers are taking the subsidy in 2006—2007 decisions need to
made early in the year.
PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION
Medicare Part D
 PCMA Primary focus- Let the market work
 PBM business model fits into the current cost conscious
environment.
 The only organization in the drug supply chain that strives to
reduce the costs of drugs.
 Over-regulation and mandates limit this effectiveness.
– E.g. Requiring coverage of drugs on formulary, limiting mail order.
– Numerous guidance, program memorandum, Q+As, etc.
PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION
Medicare Part D
 PCMA issues-Direct negotiation/Price setting
 Results in cost shift to the private sector
 Limited choice models do not work
 Government does not have a good track record in
setting prices for drugs.
– E.g. Medicaid, Medicare Part B oncology
– Not nimble enough to stay on top of a constantly changing
market place.
PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION
Part D – Consumer groups
 Traditional view- increase access without
regard to cost implications.
 Renewed focus- increased competition
among manufacturers and generic utilization.
 PCMA is working on efforts to increase
generic utilization and maintain competition.
PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION
Part D – Marketing
 PCMA member companies are putting out millions of
dollars worth of advertising.
 Marketing Guidelines- Mutual concerns with AARP
about pharmacists steering beneficiaries pharmacy
run plans.
– Possibility of cherry picking healthier beneficiaries
– Not the best plan choice for that senior
– Pharmacist is a trusted health care provider and should not
be in the role of marketing.
PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION
Part D - Transparency
 Beneficiaries have access to drug prices before enrolling in a
PDP and also once they are enrolled, available at
www.medicare.gov, each plan’s website and via each plan’s 1800 numbers.
 PDP sponsors must disclose to CMS aggregated pricing and
drug specific pricing data including:
– discounts
– rebates
– price concessions from manufacturers
 All pricing information is subject to CMS audit.
PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION
Electronic Prescribing
 Awaiting a final rule for the foundation standard.
 The need for one uniform set of standards as opposed to 51 individual
standards.
 PBMs are the leaders–
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The RxHUB- a network developed by the three independent PBMs.
The only system that provides comprehensive formulary information and medication
history.
Both standards are in process of getting ANSI accredited through NCPDP.
 Proposed rule- E-prescribing safe harbors under the Anti-Kickback
Statute and an exception under the Stark law.
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Generally positive-allows for providing “non monetary remuneration” as an incentive
for providers to use e-prescribing.
Initial read- Must comply and be compatible with e-prescribing standards to qualify for
the safe harbor. (the provider and the technology itself).
Although no value limit was proposed on the technology to qualify, there may be a cap
at some point.
PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION
Third Party Liability
 By law, Medicaid is the payer of last resort. As part of reconciliation,
changes are being made by the House and Senate to ensure Medicaid
remains the payer of last resort.
 PCMA supports this effort however, the current language fails to
achieve the objective:
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language makes PBM liable for 3rd party claims recovery,
PBMs do not take insurance risk and are not financially liable for Medicaid claims,
PBM clients are legally responsible for Medicaid claims payment,
contractual duty to the client to process claims does not translate into payment liability.
 Employers share our concern with the current language and also raise
issue with the obligation of third parties to provide states with an overly
broad and burdensome amount of coverage eligibility and claims data,
noting the different requirements for the 51 different jurisdictions.
PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION
Third Party Liability (con’t.)
 States currently engage in “pay and chase” where
the state initially pays the claim then bills the third
party insurer when applicable.
 This is not cost-effective.
 Incentives should be created for states to develop
stronger programs to identify, at the point of care,
when a Medicaid recipient has other health
insurance (and when Medicaid should be the
secondary payer).
PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION
Biodefense
 PCMA strongly opposes any language that would
decrease generic drug utilization thus increasing
overall health care costs, such as;
– orphan drug market exclusivity
– broad definition of countermeasure
 PCMA does support solutions to preparedness such
as minimizing product liability, providing tax credit for
research and manufacturing, guaranteed purchasing
and government funding.
PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION
PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION